Module 73, General Orthopaedist Level
A 10 year old male was born at term without post natal problems. His
walking was delayed until 2 years and 6 months of age. Medical treatment
to this time has been observation with several short episodes of physical
therapy aimed at stretching contracture at the knees. He is in grade five,
doing well academically and lives on a farm where he is able to do most
age appropriate farm tasks. At this time the family complains that he is
walking more with his knees flexed and his knees rub together. He had two
episodes of inhibitive casting for the hamstring contractures which the
family says only caused pain with no benefit. Now at age 14, the family
seeks a new opinion because in the last year it has become more difficult
for him to walk. His knees rub together to the point of developing contusions
from the direct contact. After working on the farm or walking long distances
he has having increasing right knee pain. He has never had hip pain. X-rays
of the hips and knees were obtained. He walks with both knees hitting in
swing phase, left pelvis posterior, and stiff knee on the left.
Question 73A
The
x-ray is a typical untreated spastic hip in a teenager.
Question 73B
The
right knee deformity is a typical valgus knee deformity common in children
with diplegia.
Question 73C
The
best treatment option would be to do a corrective osteotomy of the right
knee, then see how he walks before proceeding with any other reconstruction.
Question 73D
The
left hip needs a varus osteotomy alone to treat the subluxation.
Question 73E
The
parents are very concerned that following surgery this boy may not be able
to walk independently or may need to use crutches. You can confidently
reassure the parents that there is almost no risk of that happening.
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